The cut-off age for breast screening has been extended to 74 but is this leading to overdiagnosis and overtreatment of lesions that might never become invasive breast cancer?
This question was posed to dozens of doctors by Dr Jolyn Hersch, a postdoctoral researcher at the University of Sydney, who sought to discover how doctors and nurses working with ductal carcinoma in situ (DCIS) patients feel about the extension of the national mammography screening program which was announced in 2013.
Under the change women aged 50 to 74 are actively recruited to participate in screening every 2 years, previously the target age range was 50-69.
Many respondents thought the higher age cut-off made sense because the population’s life expectancy is increasing over time, Dr Hersch found in her study of 26 clinicians, a total of 10 surgical oncologists, six radiation oncologists, three breast physicians and seven breast care nurses.
But they also acknowledged that once a woman was over 70 the decision to screen should be based a personal assessment of risk-versus-benefit based on their overall health status.
“If a woman is 70 and in really great health, she’s probably a good candidate to continue screening,” Dr Hersch told the limbic.
Whereas some of the clinicians in the study described examples of women who might have quite severe co-morbidities. If they’ve got Alzheimer’s, severe arthritis, severe osteoporosis, if they are in a wheelchair, if they are likely to die of something else in the next five to 10 years. Those are the cases where we really want to take a step back and consider whether finding a very early pre-cursor of a possibly threatening breast cancer is really going to do more good or more harm.”
Study participants suggested that after the age of 70, a model based on shared-decision making made between a woman and her GP may be more appropriate than universal screening.
“When you have a national screening program you want to have a nice, neat age base cut-off but as people get older, there are more differences between individuals in terms of their health, ideally that should be taken into account.
Central to this concept is educating women earlier about screening mammography.
“I think if people understood from age 50 that screening has upsides and downsides it might be easier for people to wrap their head around the idea that at some point the downsides will eventually outweigh the upsides.”
Meanwhile, the interest in a “watchful waiting” or active monitoring approach – similar to what has been adopted for prostate cancer – is gaining momentum, with three international randomised trials now investigating their potential.
“It will be a few years before we have any results but I think there is the potential to show that for a subset of cases of DCIS that kind of approach may be quite safe and better for women who can avoid or at least delay treatments and side effects.”
Clinicians were also asked whether they believe DCIS needs a new name, and the views were very mixed.
“Certainly, some acknowledged the word ‘carcinoma’ does create anxiety in itself that can sometimes make it difficult to discuss less aggressive treatment, so they felt potentially a name change could help patients understand it’s not an urgent life-threatening condition and they can consider their options.
“Other clinicians thought DCIS term is an accurate reflection of what it is and it comes down to the clinicians skill in communicating that accurately that should be able to overcome the difficulties caused by the name. It is a bit of an open question.”